A facility failed to properly order, monitor, and care plan psychotropic and hypnotic medications for several residents. Issues included PRN lorazepam orders without end dates, an outdated AIMS assessment for a resident on psychotropic medication, use of quetiapine, divalproex, and buspirone without documented behavior support or monitoring, and daridorexant started for insomnia without a sleep assessment or insomnia care plan.
Unnecessary Psychotropic Medication Use: A resident with vascular dementia, agitation, anxiety, and repeated falls was prescribed multiple psychotropic medications, including scheduled and PRN quetiapine, PRN lorazepam, PRN haloperidol, Cymbalta, and Remeron. The resident’s care plan did not address antipsychotic use, the facility did not provide a requested psychotropic medication policy, and staff interviews described wandering, exit seeking, and an elopement event. The MAR showed repeated PRN psychotropic administration, while the EHR lacked documentation supporting delirium despite staff and hospice references to it.
A resident with dementia and a history of TBI remained on olanzapine at the same dose for over a year despite no documented behaviors for several months and no physician review for possible GDR in the past 9 months. A pharmacy review recommended dose reduction, but the physician cited a prior failed reduction that was not supported by the record. The DON stated the resident had not had behaviors and that the dose reduction had not been looked at, while the med time had been moved because the resident was always tired.
A facility failed to provide adequate behavior monitoring for five residents receiving psychotropic meds for anxiety, depression, insomnia, and bipolar disorder. Physician orders and care plans required staff to document the number of episodes of targeted behaviors, but TARs for each resident showed only checkmarks instead of episode counts. A CNA stated all residents had the same behavior task during the shift, and the DON said, "I don't know what happened there."
Failure to Monitor Psychotropic Medication Effectiveness: The facility did not have behavior or effectiveness monitoring documented for two residents receiving psychotropic medications. One cognitively intact resident with bipolar disorder, GAD, and OCD received aripiprazole, clonazepam, fluoxetine, and mirtazapine without behavior monitoring, despite a pharmacy recommendation for target behavior and mood monitoring. Another resident with Alzheimer’s disease, dementia, and depression received duloxetine, and staff confirmed there was no behavioral/effectiveness monitoring in place.
A resident with multiple diagnoses, including bipolar disorder and sleep apnea, was prescribed trazodone 25 mg at HS for sleep, but the chart lacked a sleep assessment, sleep care plan, monitoring of sleep patterns, or evidence that nonpharmacological interventions were tried first. The cognitively intact resident said they were a night owl, did not really have sleep problems, and did not know they were receiving a psychotropic for sleep; staff could not provide documentation supporting the indication or signed consent.
A resident with anxiety disorder had a PRN clonazepam order that remained active beyond the 14-day limit without a documented stop date, rationale for extended use, or intended duration. Pharmacy reviews repeatedly flagged the issue and recommended discontinuation or documentation, but no follow-up was documented. The MD stated the resident had severe anxiety and needed scheduled and PRN clonazepam, but no supporting documentation was provided.
PRN Psychotropic Orders Exceeded 14-Day Limit Three residents had active PRN benzodiazepine orders that remained in place beyond the 14-day limit without documented justification from the prescribing practitioner. The residents had diagnoses including dementia, anxiety, schizophrenia, chronic pain, and hospice enrollment, and the records showed PRN clonazepam or lorazepam was administered while the orders remained open-ended. The DON stated pharmacy and psychoactive committee reviews occurred, but the missing stop dates were overlooked.
A resident with dementia and severe cognitive impairment was prescribed Rexulti for behavior changes, but the medical record did not include monitoring for adverse reactions or side effects. The DON confirmed the facility typically documents psychotropic monitoring on the MAR/TAR and in the care plan, but no such documentation was present for the resident’s antipsychotic medication.
A resident with vascular dementia, agitation, and anxiety received PRN lorazepam for anxiety, but the order was not limited to 14 days and lacked a documented rationale for extended use or a specific duration. The MAR showed repeated use of the medication, and the DON stated the order was missed getting the continued order.
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